The Chief Executive of Salford Primary Care Trust

REPORT OF THE LEAD MEMBER FOR

COMMUNITY & SOCIAL SERVICES

and

THE CHIEF EXECUTIVE OF SALFORD PRIMARY CARE TRUST

and

THE CHIEF EXECUTIVE OF SALFORD ROYAL HOSPITAL TRUST

TO THE HEALTH & SOCIAL CARE SCRUTINY COMMITTEE

ON THURSDAY 17th March 2005

TITLE: Community Care (Delayed Discharges etc) Act 2003.

Report on progress March 2005

RECOMMENDATION: That the Report be noted.

EXECUTIVE SUMMARY:

Under the terms of the Community Care (Delayed Discharges etc) Act, from 5 January 2004, acute trusts are able to charge local authority social services departments £100 per night (£120 in London) for each patient who is ready to be discharged from an acute sector bed, but is awaiting a community care package to enable a safe discharge. Notice periods include Saturday as a normal working day.

Where the cause of the delay is because a further health service is needed, but not available (as part of a package, or an alternative health bed) this is not counted as a finable day.

Community and Social Services Directorate and Salford Royal Hospital Trust have worked together with other stakeholders in housing, the independent sectors and other NHS Trusts to develop protocols to manage the new arrangements under the act and to develop a range of options to ensure the delivery of the Right Care, at the Right Time at the Right Price.

This will ensure people do not remain in an acute hospital bed when they no longer need acute care, and will change the patient pathway to include intermediate care or transitional arrangements where needed.

Since the new system came into place there has been a significant reduction in the number of delayed discharge days.

The system continues to need ongoing monitoring including use feedback and education.

This matter was first considered by Health and Social Care Scrutiny Committee on 11 March 2004 and again in September 2004.

BACKGROUND DOCUMENTS: (Available for public inspection)

Community Care (Delayed Discharges etc) Act 2003, and associated Government Guidance.

Scrutiny Report Dated, March 2003.

CONTACT OFFICER: Julia Clark (Salford City Council) 793 2234

Steve Smith (Salford Royal Hospital Trust)

Catherine Caple (Salford Primary Care Trust)

WARD(S) TO WHICH REPORT RELATE(S) All Wards

KEY COUNCIL POLICIES: Improving health in Salford

Enhancing life in Salford

Salford City Council

Report to Scrutiny Committee

March 2005

Community Care (Delayed Discharges) Act 2003

Implementation in Salford

Introduction

Under the terms of Community Care (Delayed Discharges etc) Act 2003, from January 2004, acute hospital trusts are able to charge local authority social services departments £100 per night for each patient who remains in an acute hospital bed when they are deemed ready for discharge, but are awaiting a community care package to enable a safe discharge. Set periods are in place for the notification of such patients to social services and for the arrangements of care.

Where the cause of the delay is because a further health service is needed, but not available, that is not counted as a finable day.

A report was brought to Scrutiny Panel in March 2004 to report on progress in the first 6 months of implementation and a further update was presented in September 2004.

In August the government announced its’ intention to extend the cross-charging scheme to mental health, community hospitals and palliative care, though details over when it will be launched and the level of resources that will be attached have yet to be decided.

Delayed Discharges Grant

Additional funding was made available from Central Government to create support services to avoid delays, or to make payments of fines if services did not prevent delayed discharges. The amount for Salford in 2004-05 was £610,000.

This money has been allocated to the following areas:

1. Increase in Social Care Assessment Capacity within hospital = £ 67,500
2. Additional Residential and Nursing Care Beds (30 beds) = £360,000
3. Payment of fines or transitional beds = £182,500

Progress to date

There have been difficulties in recruiting additional social work staff to work in this area as Saturday working is required. Existing staff have covered Saturday working on an overtime basis. However we have recently been successful in recruiting to one of these posts and they are now an integral part of the Transfer of Care Team.

The number of finable days has remained low - in the 12 months from January 2004 until Decenber 2004 the total cost of delayed discharge fines has been £6,000. The total cost of transitional care beds from April 2004 to December 2004 has been £22,943.

In 2002 the SSI set a target of 33 people per week being identified as delays. By March 2003 Salford has about 9 delays per week. From 1st April 2004 – 31st December2004 there has been an average of 2 days delay per week for people awaiting care packages.

In the main the delays are attributable to lack of resources in EMI nursing and also to difficulties in finding suitably adapted accommodation for individuals who had acquired a physical disability. Transitional accommodation is offered to provide interim accommodation where people are waiting for a place in a specific home, which has no vacancies. Transition money is also used to fund placements when the existing Residential/Nursing Care Budget is fully committed. To date we have no specific transitional beds, there are obtained from existing providers of care.

There has however been a significant increase in the numbers of people referred from the hospital into intermediate care services in the last 2 years as illustrated below.

April 2002 – March 2003 April 2003 – March 2004

Swinton Hall3474

White Meadows316

Limes Rehab1849

This has been reflected in the reduction in the number of applications for permanent care.

2003 – January to August = 113

2003 – January to August = 71

There are still some outstanding pieces of work to be done, however in order to further improve the process. This would involve some clarification of timescales for assessment, and guidelines around the identification of delayed discharges.

Procedures and Working Together

Systems and procedures relating to Transfer of Care are being developed on a multi-agency basis across Salford Primary Care NHS Trust, Salford Community and Social Services Directorate and Salford Royal Hospitals NHS Trust using best practice guidance and evidence.

Multi agency structures have been established to facilitate this work, which is focussed on helping users more smoothly through health and social care services according to their needs.

The Transfer of Care Team in collaboration with the Practice Educator from the Acute Trust are providing a rolling programme of training to multi-disciplinary teams regarding the procedures for discharge. They are also identifying areas of concern and addressing them either by discussion with clinical staff or via the Health and Social Care Steering Group.

A joint Transfer of Care Policy was signed off by the Chief Executive of Salford PCT, Community and Social Services Directorate and Salford Royal Hospital Trust in November 2001.All these agencies have now agreed to use re-imbursement monies to fund a post for a limited period to do a dedicated piece of work to update the policy.

- This document is intended to be a working took to ensure that user/carer needs are at the centre of systems and best practice is promoted.

- Procedures are clear, robust and easily renewable.

- All elements of legislation, policy e.g. continuing care eligibility reimbursement, are co-ordinated and links made explicit.

Notification to Patients

A series of letters have been designed to inform patients of the current arrangement and to ensure they start to think about plans for discharge at the time of admission.

Links to Intermediate Care

Much progress has been made in intermediate care over recent months, which has led to improvements in access to the service.

1. Single Entry Point (SEP)

The SEP was launched at the beginning of March and is working well. It facilitates easy access by providing one telephone and one fax number for the referrer. It also provides advice and ‘signposting’ for those referrers who are unsure about what service may or may not be needed.

1. Referral

The referral documentation has very recently been amended and simplified to further improve access to the service. The key element of this is the replacement of ‘individual team names’ with ‘intermediate care’. This has transferred the responsibility for deciding ‘what intervention is needed’ from the referrer to the intermediate care service assessment team.

1. Length of Stay

The average length of stay within the bedded facilities has been historically longer than one would ordinarily expect. Steps are currently being taken to review bed management and discharge planning arrangements.

1. Admissions to Beds (Out of Hours)

Ongoing work with the multidisciplinary team, in particular the medical staffing, has resulted in access to beds outside of ‘Monday to Friday, 9am to 5pm’. This is set to continue and further expand over coming months.

1. Waiting List

Waiting times for ‘bed equivalent’ interventions (i.e. within person’s own home) have been of some concern. In addition to improved skill mix and ongoing monitoring, work is about to commence on the development of ‘functional care pathways’. Once completed the pathways should help to transcend traditional professional boundaries, increase multi-disciplinary working and further the integration of the service. This would lead to a reduction in the need to ‘wait’ for certain ‘disciplines’ who are historically in great demand but short supply.

Developments within Salford Royal Hospital

At the last presentation to Scrutiny Committee the establishment of a temporary ‘Transfer of Care Area’ (intermediate and transitional care) in the hospital was proposed as a way of providing additional capacity to the health and social care community and to enable the hospital to manage patient journeys more efficiently. This would be the first phase of a two-phase plan, with the second phase involving the improvement of access to intermediate and transitional care outside the hospital so that hospital beds can be closed altogether. This idea offers the following benefits:

• The hospital can eliminate the incidence of patients outlying in beds that are not specialised to deal with their particular problems. This will improve patient care by making sure that the appropriate medical skills are on hand, and at the same time realise efficiencies in medical workload. Doctors will be able to review their caseloads in one place, rather than tracking patients in different wards across the hospital.
• The hospital can help the health and social care community to expand intermediate and transitional care temporarily, whilst working jointly on more permanent solutions.
• Patients suitable for transfer of care can be managed in one area. This would enable monitoring of the numbers and length of wait for assessment more easily and thereby support our partner agencies in their improvement plans.
• The hospital would stand a realistic chance of moving patients out of acute medical beds. At the moment, patients suitable for transfer of care are offered a transitional bed by Social Service, and as soon as they realise that this means moving to a temporary bed in a community facility they refuse to move.
• The Early Supported Discharge Team (Physio and OT) and the Transfer of Care Liaison Team could treat the area as a ward base and concentrate their efforts in one place.
• Rather than being bound by existing definitions of intermediate and transitional care, we should first understand the needs of this patient group and then create the right environment and services to support then outside the hospital. A ‘Transfer of Care Area’ could be used as a test bed for this purpose, instead of looking at patients who are pre-selected to fit particular criteria.
• The facility could be managed by the PCT. Beds can then progressively be reduced as the PCT is able to establish them in the community, or improve access to the existing intermediate and transitional care facilities.
• Medical cover could be provided by GPs, with consultant advice close at hand. This moves the health and social care community towards the locality model favoured in the SHIFT Project.

These plans have now moved forward significantly and it is now planned that a Transfer of Care Ward will be established from early April 2005.

Developments within Community and Social Services Directorate

In November the In-House home care service piloted a new short-term re-enablement home care service to ensure a swift response to hospital discharges, focusing on improving independence through an intensive goal planning approach to home care.

This has been successful by tailoring the amount of care needed on a daily basis and reducing reliance on home care. Where long-term care is needed the care is then purchased within the independent sector. This has proved very successful.

Plans to convert the remaining In-House service into a re-enablement service within the next 12 months are ongoing.

Community and Social Services is currently working with Manchester Care to provide two residential care homes within the city, one in Irlam and one in Little Hulton. There is potential to use some of these beds for Intermediate Care or Transitional Beds, available from February 2006.

Developments within the Primary Care Trust

The PCT is planning to pilot a ‘case management’ approach for people with chronic conditions. This will impact on the use of hospital beds.

Housing Adaptations: As more dependent people remain living at-home the need for suitable housing is paramount. Currently there is a long waiting time for adaptations due to budgeting issues, which need to be considered separately. In the long term the city would benefit from having all housing maintenance programmes reflecting the future needs of tenants.

Other hospitals

Whilst 80% of patients are discharged from Salford Royal Hospital, a number of Salford Residents use North Manchester General, Central Manchester, Trafford and Bolton Hospitals. The East and West Older Peoples Teams have links into these hospitals to manage these discharge arrangements.

Use of Reimbursement Money

Community and Social Services have paid around £7,000 in fines to the Salford Royal Hospital Trust. It is agreed between these two parties and the PCT that this money should be used to address pressure points within the system. The steering group have identified the need for the transfer of care proceedings to be updated (from 2001) to reflect all the current practice in this area, to ensure the processes in place are working effectively and to assist in reviewing agreed timescales for assessments. It is therefore proposed that £10,000 be set aside to employ someone for this work for a four month period. We are currently in the process of recruiting to this post.

Future Progress

The joint health and social care steering group will continue to meet regularly to monitor progress. This should be expanded to include a representative from the Mental Health Trust.

Report compiled by:

Julia ClarkCommunity and Social Services Directorate

Chris EntwistleCommunity and Social Services Directorate

Steve SmithSalford Royal Hospital Trust

Anne LouttitSalford Royal Hospital Trust

Catherine CapleSalford Primary Care Trust